- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $239.86
| Facility | | $239.86 | $239.86 | $239.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $239.86
| Professional | | $239.86 | $239.86 | $239.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.88 / $253.68 / $257.33
| Professional | | $214.88 | $253.68 | $257.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.75 / $197.71 / $248.60
| Professional | | $195.75 | $197.71 | $248.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.78 / $228.45 / $685.35
| Facility | | $105.78 | $228.45 | $685.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.17 / $258.68 / $282.19
| Professional | | $235.17 | $258.68 | $282.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.05 / $258.68 / $265.73
| Professional | | $221.05 | $258.68 | $265.73 |